‘’LAPAROSCOPIC CHOLECYSTECTOMY- CORRELATION OF PRE OPERATIVE WITH INTRA OPERATIVE FACTORS ASSOCIATED WITH DIFFICULT CASES’’

Abstract

Background: Cholelithiasis is the most common biliary disease. Gallstones are present in 10–15% of the general populations and are asymptomatic in most of them (>80%); moreover, the prevalence of gallstones varies widely in different parts of the world. Approximately 1–2% of asymptomatic patients will develop symptoms requiring cholecystectomy per year, making cholecystectomy the most common operations performed by general surgeons. Laparoscopic cholecystectomy (LC) has become the procedure of choice for management of symptomatic gall stone disease.  Laparoscopic cholecystectomy is the gold standard treatment for symptomatic cholelithiasis. However, of all Laparoscopic cholecystectomies, 1-13% requires conversion to an open surgery. Thus, for surgeons it would be helpful to establish criteria that would predict difficult laparoscopic cholecystectomy and conversion preoperatively. The objective of the study was to compare preoperative parameters with intraoperative parameters associated with difficult laparoscopic cholecystectomy.

Aim and objectives- The present analytical cross-sectional study was conducted on 68 patients to the department of general surgery in central India institute in the period from November 2020 to October 2022. The main aim of the study is ‘’laparoscopic cholecystectomy- Correlation of pre operative with intra operative factors associated with difficult cases’’.

Methods: Analytical cross-sectional study includes 68 patients having symptomatic cholelithiasis. All patients underwent elective LC in Department of General Surgery in tertiary care center at GMC Shahdol. The collected data of preoperative factors include sex, age, previous attack, obesity (BMI), lower abdominal scar, palpable gallbladder, wall thickness of gall bladder, pericholecystic collection and impacted stone in Hartman’s pouch and intraoperative factors include gall bladder adhesions to bowel and adjacent structure, duct and artery clipping, omental adhesions and extraction of gall bladder.

Results: A total of 68 patients were included in this study from November 2019 to October 2021 majority of them were female (N=50). The mean age was 46.31 years (range: 18–80 years). Most patients were in the age group of 40–49 years. Female to male ratio of 2.77: 1. Ultrasonography findings 5 patients had impacted stone, 14 patients had wall thickness greater than or equal to 4 mm, and pericholecystic collection was present in 4 patients. Acute cholecystitis was recorded in 21 subjects, 32 subjects have BMI above 25, 5 patients had history of prior abdominal surgery, 3 patients had palpable gall bladder, 14 patients had gall bladder wall thickness above or equal to 4mm, 4 patients had pericholecystic collection and 5 patients had impacted stone in Hartman pouch and these were considered difficult subjects for laparoscopic cholecystectomy preoperatively. 27 underwent difficult laparoscopic cholecystectomy. 19 subjects had difficult laparoscopic cholecystectomy, 5 patients out of 7 had BMI above 27.5 who underwent difficult laparoscopic cholecystectomy, 2 of the 5 subjects had history of prior abdominal surgery underwent difficult laparoscopic cholecystectomy, 9 out of 14 subjects with gall bladder wall thickness above or equal to 4mm had difficult laparoscopic cholecystectomy, 2 out of 4 patients had pericholecystic collection who underwent difficult laparoscopic cholecystectomy and 5 patients who had impacted stone in Hartman pouch underwent difficult laparoscopic cholecystectomy. Out of 27 difficult laparoscopic cholecystectomy, 5(18.52%) were converted to open cholecystectomy due to two with dense adhesions with multiple calculi, empyema of gall bladder, frozen calots and Type 1 mirzzi syndrome.

Conclusions: The difficult laparoscopic cholecystectomy and conversion to open surgery can be predicted preoperatively based on number of previous attacks of cholecystitis, body mass index, prior abdominal surgical history, gall bladder wall thickness and impacted stones in Hartmann's pouch